End-of-Life Care Initiated in the Emergency Department: Rethinking Escalation Pathways and Opportunities for Goal-Concordant Care

Authors

• Jennifer L. Hunter, University of LynchburgFollow

Specialty

Emergency Medicine

Advisor

Dr. Sarah Bolander

Abstract

ABSTRACT

For many patients nearing the end of life, the emergency department (ED) serves as the final clinical decision point that determines whether care escalates toward intensive life-sustaining treatment or shifts toward comfort-focused care. However, ED systems are rarely designed to facilitate structured end-of-life decision-making, and default escalation pathways often route patients to intensive care. Without standardized identification processes and structured EOL workflows, critically ill patients are frequently admitted to the intensive care unit (ICU) by default. This pattern reflects the system’s design and ingrained norms of rescue-oriented care more than intentional alignment with patient goals. ICU-based EOL care has consistently been linked to higher costs, increased symptom burden, and family-reported misalignment with patient preferences, while also contributing to the strain on critical care capacity.

This synthesis examines how ED-based decisions influence late-life trajectories and assesses emerging ED-adjacent models that challenge the inevitability of ICU escalation. Evidence from ED-based ICUs and observation-unit pathways indicates that structured, time-limited decision areas within or near the ED can clarify goals of care, support family presence, and enable symptom-focused management without automatic ICU transfer. These settings may serve as a clinical “decision space,” providing time for family presence, prognostic clarification, and shared decision-making before committing patients to intensive care routes. Although current data are limited and varied, these models show that late-life trajectories can be intentionally shaped rather than passively inherited.

Reframing the ED from a point of escalation of care to a deliberate place for values-driven decision-making has significant implications for patient dignity, family experience, clinician moral distress, and health system management. As the population ages and the demand for critical care grows, incorporating structured EOL pathways into ED workflows is not only a clinical improvement but also an essential step in how health systems support dying patients and their families. Future research on implementation is crucial to evaluate scalability, sustainability, and the effects on patient-centered outcomes.

Recommended Citation

Hunter JL. End-of-Life Care Initiated in the Emergency Department: Rethinking Escalation Pathways and Opportunities for Goal-Concordant Care. University of Lynchburg DMSc Doctoral Project Assignment Repository. 2026; 8(1).